(207) 786-3554 info@northcountryassociates.com
North Country Associates - A Maine Senior Living Management Corporation
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Employment Application (1)

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Personal Information

*
*
Facility*
Select the facility(s) that you wish to apply to - Check all that apply
Have you ever worked for a North Country Associates' affiliated facility before?*
Are you currently authorized to work in the United States?*
Do you currently meet the State's healthcare worker vaccination requirements (meaning you are either vaccinated or qualify for a medical exemption)? NOTE: The COVID vaccination is no longer required; however, MMR, Varicella, and Influenza are required vaccinations. If you are granted a medical exemption, there may be specific masking requirements.*
If "No", are you willing to receive the required vaccinations?*
Are you seeking employment for: (please indicate all that you are willing to work)*
Which work shift do you prefer? (IE first, second, third)
Please indicate the amount of pay that you expect.
Please provide a specific date, or a timeframe (IE two weeks after hire, right away, other)

NCA Statement & Practices

All employment practices and procedures will be free from prejudicial discrimination. All decisions concerning hiring, firing, transferring, promotion, discipline, training, job opportunities, wage and salary levels, etc., shall be made without discrimination, in compliance with the federal and state laws. We will employ disabled individuals who are able to perform the essential duties of a position either without special accommodations or with reasonable accommodations (so long as they can be accomplished without undo hardship to the organization or its employees). If applying to work in Massachusetts: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

Education

Where did you attend high school & college? (Click the + button to add a new row)*
School Name & Address
Major
# of Years Completed
GPA
Degree/Diploma
 
Please let us know about any special training or education that you would like us to consider. (IE business college,other special courses...including military training, post graduate and nursing)
Which type of work are you seeking? Please indicate your top three choices for most desired work area. (Click the + to add additional rows.) Our common work areas include: CNA,CRMA,CMT,PSS, RN,LPN, Dietary Aide, Housekeeping, Office and Administration.*
Desired Position
Preference (First, Second or Third)
 

Professional References

Professional References: Please list 3-5 people we may contact who are qualified to evaluate your capabilities. Do not include friends or family. (Click the + button to add a new row)*
Name
Address
Occupation
Telephone Number
 
(Students please include academic/clinical reference)
If you are currently employed, may we contact your current employer?*
Have you ever been excluded from participating in any state or federal health care programs including Medicare or Medicaid?*

Employment History

Please give accurate, complete full-time and part-time employment record. Start with present or most recent employer. Please click the "+" symbol to add additional previous employers.
Employment History*
Company Name
Company Address
State Job Title and Describe Your Work
Telephone
Start Date (state month and year)
End Date (state month and year)
Reason for leaving?
May we contact?
 

This section is to be completed by Licensed Professionals and/or certifications. All others can skip by clicking "Next" at the bottom of the page.

Are you currently registered, licensed or certified?*
License or certification information*
Type
State Issued
Expiration Date
Certificate or License Number
Are there any restrictions on this license (Yes or No)
 
Please enter all of your professional license and/or certification data here.
Have you ever received a letter of concern or any form of disciplinary action against your professional license?*

General Information and Acknowledgement

Notice to All Applicants

For the purpose of the following question, the definition of a crime is any act or the commission of an act that is forbidden or the omission of a duty that is commanded by a public law and that makes the offender liable to punishment by that law. Punishment may include a fine, jail/prison sentence, probation, restitution, etc. If you have been to court and/or paid a fine for an offense other than a minor traffic violation, you may likely have a criminal record. IMPORTANT: Be sure to answer this question honestly. A previous conviction may not automatically disqualify you for employment. However, should you be offered employment and this information is determined to be false or if you neglected to reveal the full details of your criminal history, the offer of employment may be rescinded.
Criminal History*
Have you ever been convicted of, or are you presently charged with, any crime other than minor traffic violations? ( Drunk, reckless or hit-run driving are not minor violations.)
Convictions
Offense
Date of conviction
Sentence
 
If yes, please provide information regarding any current charges and/or previous convictions of any crime, other than a minor traffic violation.

Acknowledgement and Consent

Please read carefully and sign in acknowledgement If employed, this application will be made a part of your personnel record. Any misrepresentation or omission of pertinent facts will be cause for immediate dismissal. I understand that North Country Associates will conduct a criminal history background check if I accept a contingent offer of employment. I also understand that employment at North Country Associates or any of its affiliated facilities is always based on the ongoing mutual agreement of the employee and the employer. This means that employees are free to terminate the employment relationship at any time, with or without cause, and that the employer has the same privilege. I recognize that although I may be employed to work in a specific schedule, operating needs may require me to work my share of weekends, holidays, or shift rotation in order to perform work need to be completed.
Please acknowledge that you have read and agree to the "Acknowledgement and Consent" above:*
Printing your First Name + Middle Initial + Last Name will act as your digital signature.
MM slash DD slash YYYY
Accepted file types: doc, docx, rtf, txt, pdf, Max. file size: 50 MB.
If you have a resume you'd like to attach, please do so here. This is not required.
Accepted file types: doc, docx, rtf, txt, pdf, Max. file size: 50 MB.
Please upload your cover letter here. You may also copy and paste the contents of your cover letter in the space below.
This field is for validation purposes and should be left unchanged.

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